Makindo Medical Notes

Related Subjects: | Nikolsky's sign | Koebner phenomenon | Erythema Multiforme | Pyoderma gangrenosum | Erythema Nodosum | Dermatitis Herpetiformis | Lichen Planus | Acanthosis Nigricans | Acne Rosacea | Acne Vulgaris | Alopecia | Vitiligo | Urticaria | Basal Cell Carcinoma | Malignant Melanoma | Squamous Cell Carcinoma | Mycosis Fungoides (Sezary Syndrome) | Xeroderma pigmentosum | Bullous Pemphigoid | Pemphigus Vulgaris | Seborrheic Dermatitis | Pityriasis/Tinea versicolor infections | Pityriasis rosea | Scabies | Dermatomyositis | Toxic Epidermal Necrolysis | Stevens-Johnson Syndrome | Atopic Eczema/Atopic Dermatitis | Psoriasis

Commonly begins during early puberty with increased activity throughout the teens, with spontaneous resolution thereafter.

About Acne Vulgaris

• Inflammation of the pilosebaceous unit of the skin.
• Affects mainly adolescents and may cause scarring.

Aetiology

• Multifactorial; possibly includes a genetic component.
• More common in males during adolescence, but more common in females during adulthood.
• Involves hormones, inflammation, skin lipid composition, and sebum production.
• Associated with overgrowth of *Propionibacterium acnes*.
• Characterized by hyperproliferation of epithelial cells leading to obstructed ducts.
• Pathology shows distension of the pilosebaceous unit with neutrophils.

Old Myths

• Acne is caused by dirt or poor personal hygiene.
• It is due to a poor diet.

Causes/Exacerbating Factors

• Congenital adrenal hyperplasia, Polycystic ovary syndrome.
• Cushing's syndrome, high androgen levels.
• Drugs such as steroids, lithium, and some antiepileptics.
• Any condition causing androgen excess.

Clinical Presentation

• Primary lesion = microcomedo (clinically unrecognizable).
• Open comedones (whiteheads) without inflammation.
• Closed comedones (blackheads) caused by melanin oxidation.
• Papules, pustules, nodules, and even cysts may develop.
• Can affect the torso, neck, chest, and shoulders.
• Symptoms may worsen during menstruation.

Acne Conglobata

Acne Conglobata is a rare but severe form of acne characterized by deep, inflamed nodules, abscesses, and interconnected sinuses that can lead to extensive scarring. It primarily affects the face, chest, back, and shoulders, and is one of the most severe forms of nodulocystic acne

Severity

• Mild: Open and closed comedones with or without sparse inflammatory lesions.
• Moderate: Widespread non-inflammatory lesions with many papules and pustules.
• Severe: Extensive inflammatory lesions, which may include nodules, pitting, and scarring.

Investigations

• Rarely needed except in unusual or very severe presentations.
• Tests: FSH, LH, Prolactin, SHBG, Testosterone, 17(OH) progesterone.
• Abdominal CT if an adrenal tumour is suspected.

Differential Diagnoses

• Folliculitis.
• Acne Rosacea.
• Adenoma Sebaceum.

Management: See NICE Acne vulgaris: management (NG198)

• Skin care: Use non-alkaline (pH-neutral or slightly acidic) cleansers twice daily. Avoid oil-based products. Advise makeup users to avoid oil-based products and to remove makeup daily. Avoid persistent picking or scratching to reduce scarring.
• Diet: Advise a balanced, healthy diet; no specific diet has been proven effective for acne treatment.
• Acne Fulminans: Urgently refer to the hospital dermatology team for same-day assessment.

Refer to Specialists

• Diagnostic uncertainty or suspicion of acne conglobata or nodulo-cystic acne.
• Unresponsive mild to moderate acne after 2 completed courses of treatment.
• Moderate to severe acne unresponsive to prior treatments.
• Acne causing scarring or pigment changes.
• Acne with persistent psychological distress.
• Urgent referral for suicidal ideation, self-harm, or body dysmorphic disorder.

First-Line Treatments

• A 12-week course of 1 of the following treatments, adjusted for severity:
• Topical adapalene with topical benzoyl peroxide (avoid during pregnancy/breastfeeding).
• Topical tretinoin with topical clindamycin (avoid during pregnancy/breastfeeding).
• Benzoyl peroxide with clindamycin for mild to moderate cases.
• Adapalene with oral antibiotics for moderate to severe cases (avoid during pregnancy/breastfeeding).

Topical retinoids and oral tetracyclines are contraindicated during pregnancy and when planning pregnancy.

Review at 3 Months

• Assess the improvement of acne and any side effects. For those on oral antibiotics, consider stopping the antibiotic but continuing topical treatment if acne is cleared.
• If acne has improved but not fully cleared, continue oral antibiotics alongside topical treatment for up to 12 more weeks.

Oral Isotretinoin Treatment

• Consider oral isotretinoin for people over 12 years with severe acne unresponsive to standard therapy.
• For individuals under 18, ensure agreement from two independent healthcare professionals before prescribing.
• Discuss psychological wellbeing before starting treatment.
• For people at risk of pregnancy, explain the risks of isotretinoin during pregnancy and follow the MHRA pregnancy prevention program.

Steroid Management

• If an acne flare occurs after starting isotretinoin, consider adding oral prednisolone.
• Treat severe cysts with intralesional triamcinolone acetonide injections.

Images and Guidelines

• NICE Guideline: Acne Vulgaris Management (NG198)